This section of our website is dedicated to supporting Health Plan of San Joaquin providers with valuable tools and resources. Please click here if you are looking for Provider Policies documents.

Forms

 | Size: 99 KB Aug 29th, 2019 Physician Certification Form - Request for Transportation  | Size: 136 KB Jun 11th, 2019 HPSJ Prior Authorization List  | Size: 1 MB Apr 16th, 2019 SB137 Data Validation Provider Form  | Size: 1 MB Apr 16th, 2019 SB137 Data Validation Form Facilities  | Size: 286 KB Apr 16th, 2019 274 Form For Provider Practioners  | Size: 373 KB Apr 16th, 2019 274 Form For Behavioral Health  | Size: 222 KB Apr 16th, 2019 274 Form For Ancillary Facility  | Size: 436 KB Mar 27th, 2019 DRE Confidentiality Statement Form  | Size: 450 KB Jan 28th, 2019 Change Healthcare EFT-ERA Enroll Online  | Size: 350 KB Dec 12th, 2018 Me & My Baby Program  | Size: 272 KB Oct 25th, 2018 Synagis Recommendations 2018-2019  | Size: 277 KB Oct 25th, 2018 Synagis Authorization Form 18-19  | Size: 276 KB Apr 26th, 2018 Offset Request Form  | Size: 608 KB Apr 17th, 2018 Provider Dispute Resolution Request Form  | Size: 137 KB Feb 2nd, 2018 Outpatient Palliative Care Referral Form  | Size: 171 KB Jan 24th, 2018 Primary Care Physician / Main Doctor Change Form / English - Spanish  | Size: 295 KB Nov 8th, 2017 Member Appeal Form  | Size: 221 KB Nov 2nd, 2017 Medication Prior Authorization Form  | Size: 340 KB Nov 2nd, 2017 Disease/Case Management Referral Form  | Size: 19 KB Jun 21st, 2016 Diabetes Outpatient Education Referral Form - Doctors Medical Center only  | Size: 340 KB Jun 20th, 2016 CHEER Program Referral Form  | Size: 237 KB Oct 29th, 2015 UM Appeal Cover Sheet  | Size: 505 KB Oct 20th, 2015 Specialist Referral Form  | Size: 44 KB Jul 17th, 2015 Western Drug DME Order Form
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Posted on June 17th, 2015 and last modified on August 29th, 2019.

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